The Relationship Between Organizational Factors and Performance Among Pay-for-Performance Hospitals

1. The Relationship Between Organizational Factors and Performance Among Pay-for-Performance Hospitals Vina ER, Rhew DC, Weingarten SR, Weingarten JB, Chang JT.

2. Background • Pay for Performance (P4P) • Hospital Quality Incentive Demonstration (HQID) Project • Rewarding high performance hospitals with 2% bonus on Medicare payments

3. Objective • To identify the key quality improvement (QI) factors associated with higher performance in hospitals in a P4P program

4. Sampling frame • Hospitals participating in the HQID project across 5 clinical conditions or procedures: • Acute myocardial infarction (AMI) • Heart failure (HF) • Pneumonia (PN) • Total hip or total knee replacement (THR/TKR) • Coronary artery bypass graft (CABG)

5. Study sample

6. Overall Composite Quality Score (O-CQS) • Overall Composite Quality Score (O-CQS) • Calculated by Premier, Inc. • Utilized O-CQS from year 2(October 1, 2004 - September 30, 2005) • Combines composite process score (CPS) and composite outcome score (COS)

7. Structured telephone interview • Telephone interviews were conducted by Zynx Health investigators (blinded to each hospital’s performance ranking): July, 2007 - October, 2007 • Average interview: ~35 minutes • Respondents were asked to focus on theirQI activities during the past year

8. QI domains • Quality improvement (QI) interventions • Data feedback systems (quality compliance) • Physician leadership • Organizational support for QI • Organizational culture

9. Results • 92 hospitals were eligible for the study • 84 (91%) completed the interview • 45 were in the top 2 deciles • 39 were in the bottom 2 deciles

10. Hospital characteristics

11. QI interventions *P < .01

12. QI interventions *P < .01

13. QI interventions: Electronic capabilities

14. Data feedback

15. Physician leadership • Among hospital CMOs with the general role of improving quality, • Percentage who recruited “physician champions” (82.1% vs 69.4%, P<.05).

16. Organizational support

17. Organizational support

18. Organizational support

19. Organizational culture

20. Organizational culture

21. Organizational culture

22. Organizational culture

23. Organizational culture

24. Limitations • Voluntary participants in a P4P program • Participants not blinded own performance rankings • Unable to evaluate association of QI efforts to future performance

25. Conclusions • Main factors associated with high performance: • Organizational structure • Organizational support for QI • Organizational culture

26. Policy implications • Strategies should encourage development of improved organizational structure, support and culture for quality • Develop and strengthen resources to support QI activities

27. Acknowledgements • Zynx Health, Inc. • Premier, Inc. • Centers for Medicare & Medicaid Services

28. Questions?

29. References • (1) Centers for Medicare and Medicaid Services (CMS) / Premier Hospital Quality Incentive Demonstration Project. Internet 2008 January 3;Available at: URL: http://www.premierinc.com/quality-safety/tools-services/p4p/hqi/hqi-whitepaper041306.pdf • (2) Centers for Medicare and Medicaid Services (CMS) / Premier Hospital Quality Incentive Demonstration Project. Internet 2008 January 3;Available at: URL: http://www.premierinc.com/quality-safety/tools-services/p4p/hqi/resources/hqi-whitepaper-year2.pdf • (3) Lindenauer PK, Remus D, Roman S et al. Public reporting and pay for performance in hospital quality improvement. N Engl J Med 2007 February 1;356(5):486-96. • (4) Bradley EH, Herrin J, Mattera JA et al. Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction. Med Care 2005 March;43(3):282-92. • (5) Bradley EH, Herrin J, Mattera JA et al. Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction. Med Care 2005 March;43(3):282-92. • (6) Marciniak TA, Ellerbeck EF, Radford MJ et al. Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project. JAMA 1998 May 6;279(17):1351-7. • (7) Metersky ML, Galusha DH, Meehan TP. Improving the care of patients with community-acquired pneumonia: a multihospital collaborative QI project. Jt Comm J Qual Improv 1999 April;25(4):182-90.

30. References • (8) Ferguson TB, Jr., Peterson ED, Coombs LP et al. Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgery: a randomized controlled trial. JAMA 2003 July 2;290(1):49-56 • (9) Fonarow GC, Abraham WT, Albert NM et al. Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Arch Intern Med 2007 July 23;167(14):1493-502. • (10) Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med 2008 January 15;148(2):111-23. • (11) Berwick DM, James B, Coye MJ. Connections between quality measurement and improvement. Medical Care 2003;41(1):I30-8.

31. BACK-UP SLIDES

34. QI Interventions

35. QI Interventions *P < .05; ‡P < .01.

36. Results, Summary